Client Intake

Emergency Contact (Name)*
Emergency Contact Number*
Emergency Contact Relationship*
What brings you to Sex and Intimacy Coaching? (Please share briefly what you'd like to explore or work on.)*
What are your current goals for this work?*
Do you have prior experience with therapy, coaching, or personal development work?*
If yes, briefly describe:
How would you describe your relationship to your body and emotions?*
Are you currently in a relationship(s)?*
If yes, how would you describe it?
What are your desires, challenges, or curiosities in your relationships or intimacy?*
Do you have any concerns, fears, or boundaries you would like me to be aware of as we work together?*
Have you experienced trauma, stress, or events that have impacted your relationship with your body, intimacy, or sexuality?*
If yes, please share only what feels comfortable:
Do you have any physical conditions, injuries, or sensitivities that I should know about?*
Do you practice any form of mindfulness, movement, or bodywork (e.g., yoga, dance, meditation)?*
What are your expectations or hopes for our sessions together?*
Do you have specific modalities or practices you are interested in exploring (e.g., touch, guided visualization, movement)?*
Are there any specific boundaries or preferences you’d like to share?
I understand that Somatic Sex and Intimacy Coaching may include verbal and experiential practices designed to help me connect with my body, emotions, and desires. I understand that my participation is voluntary, and I can set boundaries or stop at any time.*

© Tovah Petra Kolodinski
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